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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803974
Report Date: 01/09/2024
Date Signed: 01/09/2024 02:38:47 PM

Document Has Been Signed on 01/09/2024 02:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:L & S GENTLE CARE IIFACILITY NUMBER:
486803974
ADMINISTRATOR:PADAMA, SAMUELFACILITY TYPE:
740
ADDRESS:778 APPALOOSA CTTELEPHONE:
(707) 846-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
01/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Samuel Padama, AdministratorTIME COMPLETED:
02:52 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced for the purpose of a case management. LPA was greeted by Caregiver. Administrator Samuel Padama arrived at approximately 9:50am.

On 1/08/2024 CCL received Incident Report for incident occurring on 1/04/2024 indicating resident R1 had a pressure ulcer on their right hip.

RN for R1 arrived to facility while LPA was present. Per LPA interview with R1's RN, the purpose of RN's visit today is to stage the ulcer. LPA advised Admin that stages 3 and 4 pressure ulcers are prohibited. Per Title 22 regulation 87615(a)(1): Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.

Per LPA interview with R1's RN, the pressure ulcer is currently unstagable. Per RN, they cannot determine what is under the ulcer's slough. Per RN, there is a yellow slough on the skin which covers the wound bed of the ulcer, and as such, RN is unable to determine at what stage the ulcer is under the slough. Per RN, the presence of a slough does not necessarily mean the ulcer below the slough is at stage 3 or 4, it could be at stage 2. RN cannot see the wound bed. Once slough is removed then the wound can be staged. RN will be treating the pressure ulcer with Medihoney with calcium alginate in order to remove the slough and cover the ulcer with foam dressing, every week, twice a week. Resident will be reassessed for staging in approximately 4-6 weeks.

Family member of R1 was present during LPA visit. Family member reported to LPA that R1 is receiving prompt medical care when needed. Family member feels that the Admin and caregivers are attentive at providing care. Admin ensured that resident is being moved every two hours, per RN orders, in order to mitigate pressure on right hip.

Continued on 809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: L & S GENTLE CARE II
FACILITY NUMBER: 486803974
VISIT DATE: 01/09/2024
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Continued from 809...

Upon arrival, at approximately 9:40am LPA observed medication closet in hallway that houses centrally stored medications to be unlocked, medications accessible. LPA advised Caregiver that medicine closet must remain locked at all times. Approximately five minutes later LPA walked back through hallway, LPA observed medicine closet to still be unlocked. LPA again advised caregiver to keep medication closet locked. Per Title 22 regulation 87465(h)(2)-- Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication (deficiency cited, see 809D).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2024 02:38 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/09/2024 at 01:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: L & S GENTLE CARE II
FACILITY NUMBER: 486803974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2024
Section Cited
CCR
87465(h)(2)

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87465(h)(2) Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...

This requirement is not met as evidenced by:
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Admin to administer staff training to ensure that staff know how to properly store centrally stored medication per regulation 87465(h)(2). Admin to submit LIC9098 self-certifying training completed. Admin to submit LIC9098 by Plan of correction due date of January 22, 2024.
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Based on LPA observation medication closet housing centrally stored medications was left unlocked, which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
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